Monday, November 24, 2008

Not Young Anymore

First of all this is not a photo of me. Although, it could be. This is Daniel Callahan of the Hastings Center in Garrision, NY.

Being an RN I've complained on the blog from time to time of the inappropriate medical treatments given to the chronically ill, frail and aging person.

Daniel Callahan has been waging a quiet battle to protect the elderly from medical advances that, although they may add a week or a month to a person's life, are often painful and cruel and steal from that person days of comfort with family or friends. Here is his most recent essay with introduction by Jane Gross of the NYT. Please follow the link to his original article in the New York Times.

November 24, 2008, 6:00 am — Updated: 2:34 pm -->
Rationing Health Care
By Jane Gross
A guest post earlier this month by Daniel Callahan, the co-founder of the Hastings Center, a caldron of research on bioethical issues, dissected the hot-button issue of rationing health care based on age as a way of preventing a total collapse of the Medicare system. Rationing could, arguably, improve the quality of life for America’s aged by leading us to think twice about invasive tests, cutting-edge surgery and other treatments that may extend life briefly but at a high cost, not only in health care dollars but also potential suffering for limited gain.
I was struck not only by the volume of comments to Mr. Callahan’s essay but by how many readers wholeheartedly endorsed, or at least were willing to consider, a form of cost-containment that has long been radioactive to policymakers. His reading of your comments was far more nuanced than mine and led him to write the following response. It is both an acknowledgment of your interest, passion and thoughtfulness and an opportunity to further parse the possible solutions to a daunting societal problem. Read on. Daniel Callahan, co-founder of the Hastings Center in Garrison, N.Y.
The Woes of Medicare: A Response to ReadersBy Daniel Callahan
The response to my guest blog post, “The Economic Woes of Medicare,” was overwhelming, full of interesting and thoughtful comments. A fair proportion of readers agreed with me, probably more than I would have gained 20 years ago. But I was also distressed by the wide and often contradictory range of the comments. What, I wonder, would it take in Congress to achieve a consensus on the future of Medicare if your responses are at all representative of public opinion more broadly?
It might take a miracle to cut through that thicket, but perhaps some sorting and winnowing is possible as a first step.
Age-based rationing, even of the relatively soft kind I propose, will have an uphill struggle but, combined with other considerations, might slip by. Health care economists have devised the idea of quality-adjusted-life years, or QALYS, as one way to measure economically sensible treatment. Its aim is to determine how many years of added life, and with what quality, a particular treatment would bring. That standard can be used with any age group and would by no means automatically rule out aggressive high-tech treatment of the old, though it could set the bar very high. QALYS is used in many European countries to influence decisions about which procedures are covered for whom.
Universal health care, supported by many of my readers, would be exceedingly valuable. It would bring some coherence to the excessively expensive mix of public and private health care that marks, and mars, our system. It would also allow the possibility of allocating resources better among age groups. Children are now losing ground to the old, but the old are not necessarily getting what they need most for the amount of money spent on them. Universal health care, I hasten to add, would have to be government-dominated to curtail the commercialism and profiteering so many complained about.
The idea of having a two-tier system has some appeal. That would mean setting a maximum level of Medicare support and then allowing, or forcing, the elderly to pay for additional costs on their own. Everyone would get something, but not the open-ended kind of benefits now available for high-tech treatments. If the base level was not high enough, however, many people would simply not be able to afford expensive procedures or protracted stays in I.C.U.’s (running into the tens of thousands of dollars). If the base level was too high, then the Medicare program could not sustain it. A possible solution might be the purchase of a tax exempt catastrophic insurance policy prior to old age. But none of these possibilities would make any sense in a health care system unable to control costs; everything would soon fall apart.
What about greater efforts at disease prevention, particularly if accompanied by a denial of treatment for those with poor health behavior? While prevention sounds like a good idea, it is not a sure shot. Some prevention is expensive — C.T. and M.R.I. scans, for example, and even effective educational efforts to change behavior — and it may well be that prevention just defers illness later into old age.
As for penalizing those who fail to take care of themselves, there are two objections. One of them is the difficulty of determining in a fair way when someone is truly culpable for his bad health. We all know people who have struggled unsuccessfully to control their weight. Should they be shut out from care? Many poor people can only afford poor diets and have little or no opportunity for physical fitness. Another objection is that penalization flies in the face of an ancient medical ethic: physicians are obligated to treat the sick regardless of why they got sick. Do we want our doctors deciding whether to treat us based on their judgment of how we have lived our lives?
I suspect these debates will become harder and more complex as costs continue to rise. We will all have to give up something, and possibly something very important to us, if they are to be resolved. Even so, we will still have the longest life expectancy and the best health in American history. Not a bad consolation prize.
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